The second national U.S. Listening to Mothers survey was carried out in January-February 2006 among women who gave birth in 2005. The survey included many questions that provide timely, previously unavailable knowledge about evolving issues. This alert summarizes data that shed light on current deliberations about cesarean section and vaginal birth. It has been updated to reflect final results reported in October 2006.

What is the background to the second Listening to Mothers survey?

Childbirth Connection's national Listening to Mothers surveys give voice to those who care most about childbirth: mothers themselves. The second Listening to Mothers survey was carried out in January-February 2006 among 18- to 45-year-old women who gave birth in U.S. hospitals to a single infant in 2005, with the infant still living at the time of the survey. The survey was carried out to understand the mothers' experiences and to identify opportunities to improve maternity services and policies. The survey included continuing questions from the first Listening to Mothers survey to enable the charting of trends, as well as new questions exploring additional topics and evolving issues. 1,573 women described their experiences planning pregnancy, being pregnant, giving birth and during the postpartum period. The survey was carried out in partnership with Lamaze International and conducted by Harris Interactive. See link above for Harris Interactive's concise description of the survey methodology, including measures taken to reflect the target population. Full survey results were reported in October 2006.

The first national data from women themselves clarify that demand from women for a planned initial (or "primary") cesarean with no medical reason is infinitesimal. Despite some professional and mass media discourse about "maternal request" or "patient demand" cesarean when there is no medical indication, just one woman (0.08%) among 1314 survey participants who might have initiated a planned primary cesarean without medical reason did so. Just that one woman (0.4%) out of 252 survey participants who actually had a primary cesarean initiated a planned cesarean without medical reason. Two other women with a primary cesarean said that it was scheduled ahead of time without medical reason and initiated by a health professional. All others (98% of women with primary cesareans) believed that there was a medical reason for their cesarean. The most common reasons cited were concerns about fetal distress, position of baby, size of baby, and prolonged labor.

How is this reflected in the total population of women giving birth? Among all survey participants, 0.06% had a planned first cesarean birth by maternal request and understood that there was not a medical reason. Applying this to the most recent national figure for annual births, an estimated 2,606 women out of about 4.1 million who gave birth in 2005 had primary no-indication maternal request cesareans.

These first national results from women themselves clarify that demand from mothers for planned primary cesareans with no medical reason is virtually non-existent. Maternal request for such cesareans is not a factor in high cesarean rates. It is time to dispel these myths.

Why have professionals and the media focused on maternal request for primary cesareans without medical indication?

These discussions have been based on the unwarranted assumption that a cesarean with no identified reason on a birth certificate or in hospital discharge records reflects the mother's demand for elective surgical birth. Until the new Listening to Mothers survey results, no data sources have been available to clarify decision-making processes and the understanding of women themselves about these matters.

Moreover, many women trust their caregivers and support the idea of a cesarean if they believe there is medical reason. Women's support for provider-initiated cesareans that they believe will benefit their babies and/or themselves must be distinguished from mother-initiated planned primary cesareans with no medical benefit.

The misleading focus on maternal demand also serves to draw attention away from many legal, clinical, financial and other factors that are contributing to high cesarean rates.

Why are cesarean rates so high in the U.S.?

Numerous legal, clinical, financial, social and other factors contribute to high cesarean rates. These include professionals' fears of legal claims of malpractice and lawsuits, the failure to offer women care that lowers their likelihood of having a cesarean (such as continuous labor support or hands-on-belly maneuvers to turn babies to a head-first position), and widespread failure to offer women with a previous cesarean or a legs- or buttocks-first (breech) baby the choice of vaginal birth. Please see Why Is the National U.S. Cesarean Section Rate So High? for details about factors that contribute to the high cesarean rate in the U.S.

The great majority of pregnant women in the U.S. are healthy and should be able to expect an uncomplicated birth. If these contributing factors were addressed, our country could experience a dramatic decline in the national cesarean rate and reduction in excess risk associated with this surgical procedure.

Did Listening to Mothers survey participants experience pressure from a health professional to have a cesarean?

Listening to Mothers II asked participants whether they had experienced pressure from a health professional to undergo some childbirth procedures. Nine percent of the mothers reported experiencing pressure to have a cesarean. This pressure from professionals to have a cesarean vastly outweighs the pressure from mothers to have one. A full 25% of women who had a cesarean reported experiencing such pressure, whereas just 2% of mothers who gave birth vaginally did so.

Did Listening to Mothers survey participants believe that the current malpractice system impacts maternity care?

Listening to Mothers II asked women whether they felt that the current malpractice system had an impact on several aspects of maternity care. A large proportion of mothers believed that malpractice arrangements were affecting maternity care in a variety of ways. Forty-two percent felt that the current system leads maternity care providers to perform a cesarean section that is not really needed to avoid being sued, while 58% did not believe that this is happening. Many mothers felt that the current malpractice environment could lead to better care of patients (62%), but they also identified concerns about unnecessary prenatal testing (53%), increased charges to pay for malpractice insurance premiums (68%), and failure to offer any maternity services (40%).

What do the Listening to Mothers results suggest about trends in the national cesarean rate?

The National Center for Health Statistics released the final U.S. cesarean rate for 2010: a record-level 32.8%. This represented a greater than 50% increase over an eight-year period. The cesarean rate among the Listening to Mothers participants who gave birth in 2005 was 31.5%.

Survey results thus suggest that the steady increase in the cesarean rate is continuing. At present, an estimated one mother in three gives birth by cesarean.

How interested were survey participants in knowing complications of cesareans?

Survey participants expressed a high degree of interest in understanding complications of cesarean section. When asked, "Before consenting to a cesarean section, how important is it to learn about possible side effects of a cesarean section?", 81% replied that it is necessary to know every complication, and 17% felt it was necessary to know most complications. Two percent chose "some," and no one chose "it is not necessary to know any complications."

Currently, "patient viewpoint" standards of informed consent are in effect in many if not most jurisdictions. These standards require health professionals to inform patients about adverse effects that a reasonable person contemplating the treatment in question would want to know, rather than what the health professional thinks they need to know. Survey results suggest that in-depth informed consent/informed refusal processes are needed when a cesarean is considered in non-emergent situations. (See Related Links, below, for review comparing harms of cesarean and vaginal birth and for a booklet that can help prepare mothers to make decisions about mode of birth.)

How informed were survey participants about actual complications of cesarean section?

Most mothers were poorly informed about actual complications of cesarean section. The survey asked participants how much they agreed or disagreed with four statements about side effects of cesareans, including shorter- and longer-term effects on mothers and babies. From 42% to 46% of the mothers were "not sure" about how to reply to the four items, and an additional 22% to 33% responded incorrectly. These results raise serious concerns about the adequacy of current informed consent processes for this major surgical procedure.

Who did survey participants feel should make most decisions about their care?

The survey asked participants who should make most decisions about their labor and birth experience, assuming there are no medical complications. Consistent with their legal right to informed consent and informed refusal, 73% of mothers responded that the decision should be hers after considering advice of her caregivers, and an additional 23% supported shared mother-caregiver decision-making. Just 3% felt that caregivers should make decisions after consulting her, and less than .5% felt that decisions should be fully in the hands of caregivers.

More specifically, the survey asked the mothers to express their views about whether women should have their preferences for a cesarean or vaginal birth honored. 46% agreed that a woman should be able to have a cesarean if she wants one, and 31% disagreed (with 23% in the middle). Notably, when asked if a woman with a previous cesarean should have the opportunity to have a vaginal birth (VBAC) if she wants one, 85% agreed that she should, while only 5% disagreed (with 10% in the middle). By a margin of 93% to 1% mothers felt that a woman who had not had a prior cesarean should have a vaginal birth if she wants it.

Did survey participants in fact have free choice about their care?

The survey asked mothers whether their choices were honored in two areas. Although having a vaginal birth after a cesarean (VBAC) is generally a reasonable choice from the perspective of trade-offs in risk for women with a prior cesarean, just 11% of the women with a previous cesarean in the survey had a VBAC in 2005. Of the remaining women who had a repeat cesarean, 45% were interested in the option of having a VBAC, but more than half (57%) of them were denied this option, primarily because their caregiver (47%) or hospital (26%) was unwilling to do a VBAC.

The survey also asked women who had had an episiotomy whether they had been given a choice about that procedure. Just 18% said yes, 73% said they had not been given a choice, and 9% were not sure. This is especially troubling as serious assessments repeatedly find that liberal or routine use of episiotomy increases risk of harm and offers women no benefit (see Related Link, below).

Despite lots of talk about women's choice and cesarean section, Listening to Mothers survey results reveal that virtually no mothers are choosing to plan a first ("primary") cesarean without medical reason, while many women are not given choices about how to give birth.

Founded in 1918, Childbirth Connection has joined forces with and become a core program of the National Partnership for Women & Families. Together, these two women's health powerhouses are transforming maternity care in the United States.

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